Can doctors and nurses recognize depression in patients hospitalized with an acute myocardial infarction in the absence of formal screening?

Recognizing increased risk of depressive comorbidity after myocardial infarction: looking for 4 symptoms of anxiety-depression

BACKGROUND

Screening for depression in myocardial infarction (MI) patients must be improved: (1) depression often goes unrecognized and (2) anxiety has been largely overlooked as an essential feature of depression in these patients. We therefore examined the co-occurrence of anxiety and depression after MI, and the validity of a brief mixed anxiety-depression index as a simple way to identify post-MI patients at increased risk of comorbid depression.

METHODS

One month after MI, 176 patients underwent a psychiatric interview and completed the Beck Depression Inventory (BDI) and the Symptoms of Anxiety-Depression index (SAD(4)) containing four symptoms of anxiety (tension, restlessness) and depression (feeling blue, hopelessness).

RESULTS

Thirty-one MI patients (18%) had comorbid depression and 37 (21%) depressive or anxiety disorder. High factor loadings and item-total correlations (SAD(4), alpha = 0.86) confirmed that symptoms of anxiety and depression co-occurred after MI. Mixed anxiety-depression (SAD(4)>or=3) was present in 90% of depressed MI patients and in 100% of severely depressed patients. After adjustment for standard depression symptoms (BDI; OR = 4.4, 95% CI 1.6-12.1, p = 0.004), left ventricular ejection fraction, age and sex, mixed anxiety-depression symptomatology was associated with an increased risk of depressive comorbidity (OR = 11.2, 95% CI 3.0-42.5, p < 0.0001). Mixed anxiety-depression was also independently associated with depressive or anxiety disorder (OR = 9.2, 95% CI 3.0-27.6, p < 0.0001).

CONCLUSIONS

Anxiety is underrecognized in post-MI patients; however, the present findings suggest that anxiety symptomatology should not be overlooked in these patients. Depressive comorbidity after MI is characterized by symptoms of mixed anxiety-depression, after controlling for standard depression symptoms. The SAD(4) represents an easy way to recognize the increased risk of post-MI depression.

Impact of anxiety and perceived control on in-hospital complications after acute myocardial infarction

OBJECTIVES

We tested the hypothesis that perception of control moderates any relationship between anxiety and in-hospital complications (i.e., recurrent ischemia, reinfarction, sustained ventricular tachycardia or fibrillation, and cardiac death) in patients with acute myocardial infarction (AMI).

BACKGROUND

Anxiety is common among patients with AMI, but whether it is associated with poorer outcomes is controversial. Conflicting findings about the relationship of anxiety with cardiac morbidity and mortality may result from failure to consider the moderating effect of perceived control.

METHODS

This was a prospective examination of the association among anxiety, perceived control, and subsequent in-hospital complications among patients (N = 536) hospitalized for AMI.

RESULTS

Patients' mean anxiety level was double that of the published mean norm. Patients with higher levels of perceived control had substantially lower anxiety (p = .001). A total of 145 (27%) patients experienced one or more in-hospital complications. Patients with higher levels of anxiety had significantly more episodes of ventricular tachycardia, ventricular fibrillation, and reinfarction and ischemia (p < .01 for all). In a multivariate hierarchical logistic regression model, left ventricular ejection fraction, history of myocardial infarction, anxiety score, and the interaction of anxiety and perceived control were significant predictors of complications.

CONCLUSION

Anxiety during the in-hospital phase of AMI is associated with increased risk for in-hospital arrhythmic and ischemic complications that is independent of traditional sociodemographic and clinical risk factors. This relationship is moderated by level of perceived control such that the combination of high anxiety and low perceived control is associated with the highest risk of complications.

Recognition and treatment of depression and anxiety in patients with acute myocardial infarction

The objective of this study was to determine the ability of providers (medical residents and nurse practitioners) on inpatient cardiac units to recognize and appropriately treat patients with clinically significant depression and anxiety among a cohort admitted with acute myocardial infarction. Patients within 72 hours of acute myocardial infarction underwent screening with the Standardized Clinical Instrument for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition module for major depressive disorder (MDD), the Beck Depression Inventory (BDI-II), and the Beck Anxiety Inventory (BAI). In addition, the study psychiatrist and a treatment team clinician independently assessed whether they believed that patients had clinically significant depression or anxiety. Prescription of antidepressants and benzodiazepines during hospitalization was recorded by chart review. Assessments were completed for 74 patients. Providers identified < 15% of patients with current MDD or with a BDI score > or = 10; 11% of patients with current MDD had appropriate treatment with antidepressants. There was no significant correlation of providers' assessment of depression with current MDD, BDI scores, or psychiatrists' clinical assessment of depression. In contrast, providers identified 31% of patients with a BAI score > or = 10 and 50% of patients who were assessed by psychiatrists as anxious; > 80% of patients with high anxiety received benzodiazepines. Providers' assessments of anxiety were significantly correlated with BAI scores and with psychiatrists' clinical assessments. In conclusion, medical residents and nurse practitioners routinely under-recognize and undertreat depression among patients with acute myocardial infarction on inpatient cardiac units. Recognition and treatment of anxiety is substantially better, up to 50% of patients who are found to be anxious by psychiatrists after acute myocardial infarction remain unrecognized.

Rapid screening for major depression in post-myocardial infarction patients: an investigation using Beck Depression Inventory II items

OBJECTIVE

To determine the ability of three questions from the Beck Depression Inventory II (BDI-II) to detect major depressive disorder (MDD) in a cohort of patients hospitalised for acute myocardial infarction (MI).

DESIGN

Prospective observational study.

SETTING

Coronary care unit and cardiac step-down unit of an urban academic medical centre.

PATIENTS

131 post-MI patients within 72 h of symptom onset.

INTERVENTIONS

Patients were administered the BDI-II and participated in a structured diagnostic interview for MDD. Three individual BDI-II items (regarding sadness, loss of interest and loss of pleasure) were examined individually and in two-question combinations to determine their ability to screen for MDD.

MAIN OUTCOME MEASURES

Sensitivity, specificity, negative and positive predictive values and proportion of patients with MDD correctly identified.

RESULTS

The individual items and two-question combinations had good sensitivity (76-94%), specificity (70-88%) and negative predictive values (97-99%). Item 1 (sadness) performed the best of the individual items (48% with a positive response to the item had MDD; 3% with a negative response had MDD; over 80% of patients with MDD were correctly identified). A combination of questions about sadness and loss of interest performed best among the two-question combinations (37% with positive response had MDD v 1% with a negative response; 94% of patients with MDD were identified).

CONCLUSIONS

One to two questions regarding sadness and loss of interest serve as simple and effective screening tools for post-MI depression.

Predictors of health status for heart failure patients

Health status is poorly understood for patients with heart failure. The purpose of this study was to determine the relative importance of relevant sociodemographic, clinical, health perception, and emotional variables in predicting health status. In this study of 87 patients, health status was conceptualized as health-related quality of life, physical activity level, and symptom burden. Hierarchical multiple regression was used to determine sociodemographic, clinical health perception, and emotional variables associated with health status. Worse New York Heart Association class, higher anxiety, and higher depression predicted worse health-related quality of life. Better New York Heart Association class and higher anxiety predicted higher levels of physical activity. Worse New York Heart Association class and higher depression predicted greater symptom burden. Traditional demographic and clinical variables were not associated with health status. Although not routinely assessed, emotional variables had a major impact on health status. Interventions to improve health status should target both physical and emotional well-being.

Vulnerabilities of patients recovering from an exacerbation of chronic heart failure

BACKGROUND

Many rehospitalizations for heart failure (HF) are preventable as they are precipitated by modifiable factors. High early readmission rates suggest that patients commonly are discharged from HF hospitalizations with such problems unaddressed. The purpose of this study was to describe the prevalence of multiple risk factors for rehospitalization in patients recently discharged from a hospitalization for decompensated HF.

METHODS AND RESULTS

The following potentially modifiable risk factors for rehospitalization were evaluated in 202 patients: functional status; whether the patient lived alone; presence of anxiety, depression, or poor quality of life; and symptom status and adherence to prescribed medications, low-sodium diet, and symptom monitoring recommendations. Most patients were severely functionally impaired (70% New York Heart Association [NYHA] functional class III/IV). Of the 28% of patients who lived alone, 50% were rated as NYHA functional class III or IV. Fifty percent of patients were anxious, whereas 69% of patients were depressed. Health-related quality of life was substantially impaired. Patients reported substantial symptom burden. Adherence with recommended self-care strategies was poor: 14% weighed themselves daily, 9% of patients reported monitoring for symptoms of worsening HF, 31% could not name any symptom, and only 34% of patients taking all medications as prescribed. A total of 23% of patients had all of the following risk factors: NYHA functional class III or IV, lived alone, > or =1 comorbidities, and were depressed or anxious.

CONCLUSIONS

Patients newly discharged from a hospitalization for HF exhibit many psychosocial and behavioral risk factors for rehospitalization, although they have been judged clinically stable.